Coroner Identifies “Shortfall In Care” Following Woman’s Death From Allergic Reaction

Hospital Urged To Learn From Errors

13.12.2010

Leading medical lawyers from Irwin Mitchell have urged a West Yorkshire hospital to learn from its errors after a woman died when she suffered an allergic reaction to an antibiotic prescribed to her at the hospital.

Margaret Scales, from West Ardsley, died aged 66 at Dewsbury and District Hospital on 19 August 2009, following going into anaphylactic shock after taking a ‘cephalosporin’ antibiotic, which had been prescribed to ease her breathing before she underwent surgery to treat breast cancer.

At an inquest into her death at Bradford Coroner’s Court on 8 December 2010, Assistant Deputy Coroner Michael Bell criticised the hospital for multiple errors which occurred before and after Mrs Scales’ death, describing them as a “shortfall in care” and a “dereliction of professional duty.”

Medical law specialists at Irwin Mitchell, who represented Mrs Scales’ family at inquest, are now calling for the hospital to learn lessons to stop a similar situation from occurring in the future.

Ian Murray, a solicitor in the Medical Law team at Irwin Mitchell, said: “Mrs Scales had shown clear signs of a changing allergy status before she was prescribed with the drug which ultimately led to her death, yet this was not checked by the hospital or any alternatives considered.

“After her death, key evidence in relation to the fatal drug, including its packaging and batch number, were thrown away, and this made the investigation more difficult.

“To make matters worse, no investigation into the circumstances of Mrs Scales’ death was made, and her death was certified incorrectly by a Doctor who had not properly reviewed her medical records. This put her family through further distress and it is vital that the hospital learns from these mistakes.

“Patient safety should always be the priority for the NHS and errors of this magnitude should never happen, and we will continue to fight for the victims and families of those who have suffered as a result of these failures in care.”

At inquest Assistant Deputy Coroner Michael Bell returned a verdict of misadventure, and criticised the hospital for the “shortfall in care” which led to Mrs Scales’s allergy status not being checked before she was administered with the fatal antibiotic.

He also criticised the hospital for its “dereliction of professional duty” after it emerged that the hospital issued a death certificate before reviewing Mrs Scales’ medical records, which led to her body being embalmed and released for burial before a post mortem examination was ordered.

Dr Bell now plans to write to the Mid Yorkshire Hospitals NHS Trust in relation to the way in which Mrs Scales' death was certified and investigated by the Trust, in the hope that this will prevent similar mistakes from being made in the future.

Duncan Scales, Margaret’s son, said: “Our whole family has been devastated by my mother’s sudden death, and in particular the way in which her body was treated after her death, and nothing can ever be done to bring her back to us.

“Nevertheless, it was important that we received answers as to how and why she died, and we are satisfied that our questions have been answered at the inquest.

“Our only hope is that the hospital learns from the mistakes which caused my mother’s death so that other families do not have to go through what we have over the last 15 months.”

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